One of the most difficult root cause analyses is one that deals with safety culture and management systems.

Although I have no first hand knowledge of this case described in the link below, I would guess this is a good example of how a division can grow between managers and analysts when a root cause analysis becomes sensitive. Read this Associate Press article to get some background material:

http://www.sfgate.com/business/energy/article/Engineer-warns-of-problems-at-Ala-nuclear-plant-4653060.php

Once a root cause analyst decides they have to go to the press to “restore the focus on safety,” you know that the analyst thought that the root cause analysis report/presentation didn’t get the attention that the analyst thought was deserved. I would say that this desperate move is both a failure for the analyst and for management – nobody is a winner and everybody loses.

How can a company avoid this difficult situation? I think there are three things needed:

1) A root cause analysis system that is based on facts and guidance in the areas of management systems/culture.

2) Selecting knowledgable analysts that have the ability to work with management and help them see where improvements are needed and constantly upgrading the analyst’s skills.

3) Management that is involved in the root cause analysis process and willing to address findings with actions that make change happen.

One more thing that can help the process succeed is a rewards system for good investigations that thoroughly look for and address management system root causes.

What have you done at your facility to improve root cause analysis and prevent missed expectations on sensitive root cause analyses?

Have you had your investigation facilitators/team leaders attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training?

Have people who will investigate culture issues taken the Analyzing and Fixing Safety Culture Issues Course that we offer prior to the TapRooT® Summit?

Do you keep your investigators up to date by having them attend advanced TapRooT® Training and the TapRooT® Summit at least every two years?

Has management been trained to participate in root cause analyses and do they understand their role in making root cause analysis successful?

Does your management team understand the difference between managing industrial safety and process safety?

Are you learning best practices on improving root cause analysis and process improvement by having your program manager attend the TapRooT® Summit every year?

Things to think about (and a small price to pay) to keep your career on track and your company out of the papers.